Get Authorized Representative Form For Appeals - Coventry Health Care

Filling out the Authorized Representative Form for Appeals is an essential step for members of the MoDOT/MSHP Coventry PPO Plan who wish to designate someone to represent them in the appeals process. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. In the designated field, enter the name of the person you are authorizing to act on your behalf during the appeal process. This could be a family member, friend, or a healthcare provider.
3. Provide the address of the authorized person in the corresponding field. Ensure that you enter complete and accurate information for reliable communication.
4. Enter the telephone number of the authorized individual. This number will be used for any necessary follow-up communications regarding the appeal.
5. In the section regarding understanding the authorization terms, read through the statements carefully. You may choose to add any specific issues related to the appeal next to the description prompt.
6. Print your name in the space provided as the member authorizing representation. This step requires clarity to ensure it matches your official records.
7. Fill in the date of completion to indicate when you are submitting the authorization.
8. Sign the form in the designated area to validate your authorization for the specified representative.
9. Enter your Coventry ID number. This information helps identify your records in the system.
10. After you have completed all sections of the form, save the changes. You can then download, print, or share the form as needed.

Complete your Authorized Representative Form for Appeals online today to ensure a smooth appeals process.